Are you ready for the Auditor - AMA WA

PSR Audits
Who will look after you when
Medicare calls?
Increasingly Western Australian doctors are being subjected
to Professional Services Review (PSR) and Medicare audits.
These audits include mental health, practice nurse and chronic
disease management items.
The AMA (WA) has assisted a number of members to
manage this process and ensure due process is followed in
relation to these audits:
“I have just received a call from the PSR and they want
to come and talk to me about my use of practice nurse
items. They want to meet with me in two weeks and
audit some of my patient files.
Is that ok? How do I respond?
They also want to see my practice colleagues.
Should we agree to meet with them? How do we
prepare? Are you able to help us?”
This is just one example of a significant number of calls the
AMA (WA) receives each year from concerned and anxious
doctors who are subject to a PSR or Medicare call.
The AMA’s immediate response when they receive this type
of enquiry is to provide guidance on proactively managing
the audit. In the first instance, this is done by ensuring the
audit occurs at a time that is convenient for the practitioner
and which allows for an adequate preparation period so as to
minimise stress and practice pressure. The AMA will then
assist the member to thoroughly prepare for the audit.
The practitioner must have adequate time to seek
appropriate advice from the AMA and their medical defence
organisation. Practitioners must also have time to ensure their
medical records are adequate and contemporaneous.
The AMA is there every step of the way to assist you to
prepare for the meeting with the PSR or Medicare auditors;
this includes being present at the meeting.
Medical Records
It is a key requirement of Medicare that all medical
practitioners providing a service for which a Medicare Benefit
is payable must ensure they have contemporaneous and
accurate medical records. For a medical record to be adequate,
the contents of that record need to:
1. Clearly identity the name of the patient
2. Contain a separate entry for each attendance by the patient
for the service, and the date on which the service was
rendered or initiated
3. Provide adequate clinical information so as to clearly
explain the type of service rendered or initiated
4. Be sufficiently comprehensive that another practitioner
who is relying on this information can effectively undertake
the patient’s ongoing care.
Regarding over-servicing or the correct usage of item
numbers, any medical practitioner who is the subject of a
Medicare investigation, and ultimately the PSR, can have a
high degree of confidence in the quality and content of their
practice notes if they are consistent with the gold standard.
That is, the notes are accurate and contemporaneous.
The outcome of any review or audit is likely to be
determined by the quality and content of the patient records.
Many PSR audits do not question the medical practitioner’s
clinical management; rather, it is the failure to maintain
adequate and contemporaneous notes that exposes them.
There have been cases where medical practitioners have
failed to maintain adequate clinical notes, which has led to
a finding against them. In such situations the practitioner
has been required to pay back those amounts Medicare has
deemed to have been claimed inappropriately. Underpinning
Medicare’s position has been the fact that the notes don’t
justify the claims. Repayments can mean thousands of dollars,
but emotionally the cost can be even greater.
Following a finding of inappropriate practice, the
outcomes can be significant, including disqualification of
the practitioner’s entitlement to claim certain Medicare
rebate numbers for a period of time and, in the worst case, an
14 MEDICUS May